本文描述一位68 歲男性因前次心肌梗塞住院時，對於心臟復健不完全瞭解，仍與危險因子共 存，導致疾病復發再次入院。照護期間為2016 年9 月25 日至9 月30 日，透過直接照護、觀察及 運用Gordon 十一項功能性健康型態進行整體性評估，並加以歸納及分析，發現其健康問題有組織 灌流改變、無效性自我健康管理及焦慮的健康問題。筆者提供專業的個別性護理措施，減少疾病 造成的不適感，並且擬定符合個案需要的心臟復健計劃，指導如何達到各階段的運動目標；透過 疾病及飲食衛教，使個案瞭解導因，正視過往不良的飲食習慣，共同擬訂健康飲食菜單；因不確 定性及陌生環境，個案產生焦慮的情緒，運用建立良好的護病關係，透過安排明確的心臟復健計 畫緩解個案的不確定感。建議可將計畫內容整理成小手冊，使個案返家後仍有跡可循，增進達到 自我健康管理。期望藉此護理經驗分享，提供日後臨床照護此類個案之參考。

This article described the nursing experience of caring a 68-year-old male who was hospitalized because of myocardial infarction and not fully aware of the risk cardiac rehabilitation (CR) and still carried multiple risk factors, leading to recurrent hospitalization. The author assessed and collected the patient’s information through clinical observation, interview, and direct nursing care, and evaluated the information using the Gordon 11 functional health patterns from 9/25/2016 to 9/30/2016. The main health issues were altered tissue perfusion, ineffective self-health management, and anxiety. The author provided individual nursing interventions to reduce the discomfort caused by the disease, and drafted a CR program that meets the needs of the patient and taught how to achieve target of each stage of the exercise plan. Through health and dietary education sections, teaching the patient understand the cause of the disease and recognize the bad eating habits in the past, then working with the patient drafting a healthy diet menu. The patient was anxious because of uncertainty and unfamiliarity. We helped him alleviate the sense of uncertainty through establishing a good relationship and arranging clear CR programs. The author suggests that the contents of the program can be arranged into a manual, so that patients can follow at home and promote self-health management. We hope that this nursing experience can provide a reference nurses caring similar patients.